Obamacare has time to fix exchanges — but not forever
By: David Nather and Brett Norman and Jason Millman
October 3, 2013 07:10 PM EST

In Week One, Obamacare health insurance exchanges have been so swamped with traffic that they have been groaning under the strain.

That could be a good sign for a law that America supposedly hated — if the Obama administration can get the federal website bugs worked out before those potential customers get scared away.

“I’ve been trying nonstop. It’s not working. We can get to the third screen, and then it dies,” John Foley of the Legal Aid Society of Palm Beach County, one of the “navigator” groups that’s trying to sign up uninsured people in Florida, told POLITICO on Thursday. He said the group has put off all enrollment and told customers to come back next week.

“I keep asking people, ‘Do you know of anyone in Florida who has successfully signed up?’ I haven’t gotten a yes,” Foley said.

Administration officials say people have enrolled successfully — though they won’t release numbers — and that the website is getting better. They’ve also said all along that they didn’t expect a lot of people to enroll immediately, that people would browse the website and consider their health plan choices for a while.

And President Barack Obama likes to compare the glitchy rollout of the HealthCare.gov site to the snags that happen when Apple releases the newest iPhone or iPad. Right now, though, this is more like an iPad that crashes every time you try to open an app.

The administration does have time to fix that — but advocates on the ground want them to hurry up.

“I was desperately hoping to be on the news today with people saying, ‘I got my insurance,’” Foley said.

It’s way too early to judge everything about the Obamacare exchanges — Thursday was only the third day of a six-month open enrollment period. Health care experts say the administration has a while to get it right.

But if things don’t smooth out by November, they say, the White House may lose the chance to build confidence in the Obamacare exchanges.

“If it’s not there in a month … there’s going to be a problem,” said Joel Ario of Manatt Health Solutions, the former director of the health exchanges office at the Department of Health and Human Services.

Politically, the White House may not have to worry for a while. The administration has “bought themselves some time to work out the kinks” now that they’ve gotten through the first few days, according to Jim Manley, a Democratic strategist and former aide to Senate Majority Leader Harry Reid. And Republicans in Congress are preoccupied with the government shutdown, and aren’t as focused on the health law rollout.

But there’s also a danger that if people who need health insurance can’t get through the website relatively easily, they won’t come back and try again.

“They have to get it right by late October to mid-November,” says Caroline Pearson of Avalere Health, a consulting company that studies the exchanges.” With that time frame, people will come back. “If you’re aware enough and motivated enough to sign up on Day One, you’re motivated to come back a few days from now.”

But Foley, from the Florida group, is worried.To get insurance Jan 1, people must sign up by Dec. 15.

“There are a lot of people who need this by January,” he said. “I think if they don’t [fix] it soon, it’s a problem … It’s very frustrating for us because we’re feeling the time pressure.”

The volume is real – but not everyone visiting the site is signing up

Administration officials say the Web traffic — 7 million “unique visitors” to HealthCare.gov as of Thursday morning plus more in the state exchanges— proves that people are excited about being able to get Obamacare coverage. The slowdowns reported in states that are running their own exchanges, like New York and Washington state, suggest that the interest is real and not limited to the federal exchange.

Some of the Web traffic is clearly coming from potential customers — but health care consultants say it’s unlikely that most of them are trying to buy health insurance right this minute.

“I do think it’s real,” but “does that really mean people are going to purchase [immediately]? I think you have to be skeptical,” said Ario. “I wouldn’t expect a lot of purchases in the first month. Why would you spend money now for coverage that doesn’t start until January?”

HHS spokeswoman Joanne Peters said the site is being improved to adjust to the high volume. “Experts are working around the clock and were able to expand system capacity somewhat overnight, cutting by one-third the volume of people waiting to apply,” she said Thursday. “Work on the site continues today to meet the demand and excitement generated in just the first 48 hours of our open enrollment.”

Anne Filipic, president of Enroll America, an outside coalition of groups that’s working to sign people up for coverage, says the web traffic shows people are excited about the law, based on what they’re seeing at signup events in the states.

But even if people are just coming to the federal and state websites to look around, that’s OK, she said.

“This is the beginning of a conversation with people,” Filipic said. “They may want to spend some time checking out their options.”

Not all the problems are because of volume

Some of the hangups are clearly design issues or technical problems, according to Dan Schuyler, director of exchange technology at Leavitt Partners, which has been consulting with states to help them build the exchanges.

For example, the “please stand by” messages at HealthCare.gov are a “bandwidth issue,” Schuyler said, which can be solved by adding more capacity. But another common problem people have reported — not being able to complete security questions because the drop-down menus are blank — is a technical problem, he said.

“It’s definitely high volume, but the bigger problem is that they haven’t had enough time to thoroughly test the systems,” Schuyler said.

The administration says it has added more servers and engineers, improved the system configurations to handle more volume, and encouraged more people to use the call center.

In addition, some states are having trouble because of the design of their websites — which ask for too much information from the user before they can even get far enough into the site to browse the health insurance plans.

Maryland’s exchange, thought to be one of the most advanced in the country, ran into problems because of an account process that turned out to be more difficult than most other exchanges. Even before gaining access to the online marketplace, Marylanders are required to submit information like date of birth and social security number, which are then checked against federal data.

Maryland Health Secretary Joshua Sharfstein, who chairs the exchange board, said the unexpectedly high levels of early interest created a “bottleneck” effect that kept potential customers from entering the exchange website. Since Tuesday, the website “is definitely getting better,” and the connection to the federal data hub appears to be working, he said.

“The systems are communicating,” he said. “The tax credit amounts are being determined correctly. There’s a lot of things that we had been watching carefully that are working correctly.”

But Ario said he now believes it “will take weeks, rather than days” before the federal exchange is reliably performing all of its functions, including the complicated handoff of completed applications to the insurers that collect the payment and provide the coverage.

Complaints about problems confirming the tax credits that will subsidize insurance are rolling in from brokers in states using the federal exchange, said Jessica Waltman, vice president of government affairs at the National Association of Health Underwriters.

And the website’s not the only problem. Brokers who have tried the call center have encountered long wait times and operators who can’t address enrollment issues, she said.

But brokers using some of the more successful state exchanges — like Kentucky — are having a different experience.

“We are happy,” said Greg Schell, a broker at the Garrett-Stotz Company in Louisville. He said that although the exchange site had a few kinks to iron out, it was working.

They needed more time to build the exchanges, and couldn’t get it

From the beginning, building the exchanges was always going to be an enormous information technology project, Schuyler said — but the degree of early breakdowns with the federal website show the consequences of not having enough time for testing.

“I think if the states and the feds had had another six months, it would have mitigated the problems,” Schuyler said. “You need to be able to handle the medium volume, but you also need to be able to handle the spikes.”

But politically, that was impossible. One way or another, the health care law says people have to be able to get health coverage in the exchanges starting Jan. 1, 2014 — the same date Medicaid expansion begins in the states that have agreed to do it. To delay the deadlines in the law, the Obama administration likely would have had to go to Congress — and no fixes can get through Congress right now because of Republican opposition.

Administration officials insist that people who have gotten through the HealthCare.gov website are getting correct information on the subsidies. But Schuyler says he’s worried, based on the more basic breakdowns that have happened.

“If you can’t do something as easy as establishing an account, it really makes me nervous that it can do the complicated things, like the subsidy determination process,” said Schuyler.

The snags are affecting some states, too. Idaho, which is transitioning to a fully-state based exchange, is using federal enrollment systems in Obamacare’s first year. So that means Idahoans trying to explore their health plan options are facing the same slowdowns as everyone else in states that refused to set up their own online insurance marketplaces.

Idaho exchange executive director Amy Dowd, during a Thursday board meeting, said the state has been in regular contact with CMS about efforts to improve HealthCare.gov operations.

“They’re adding servers, they are working on things as of this morning 24/7 to try to improve performance,” Dowd said. “People are getting through, they are applying. It’s still slow, but improving.”